(7) HIV/AIDS

The Science of HIV/AIDS

HIV/AIDS – WORLD HEALTH ORGANIZATION

HIV & AIDS

HIV/AIDS BASICS

Human security

 Earlier texts assessed the demographic impact of AIDS and showed how the disease creates poverty and despair and erodes institutional capacity. Could this epidemic cause state collapse? Disease can have this impact, as was documented for the post-Columbian Americas, when the Aztec and Inca civilizations vanished.

What happens with AIDS in the worst scenarios? In Botswana, it was predicted in 2002 that, in the absence of dramatic behaviour change or scientific advances, 80% of 15-year-old boys would die of AIDS (mortality would be even higher for girls but was not publicized as it was deemed ‘too depressing’). In Swaziland, life expectancy is only 31.3 years and will decline further, infant and child mortality are rising, and the proportion of orphans will increase. In these settings, state collapse must be a real possibility.

Political scientists Andrew Price-Smith and John Daly directly implicate the epidemic in the disintegration of Zimbabwe. They argue that AIDS operates simultaneously across various domains to destabilize states and threaten their national security.

Zimbabwe faces many crises: economic contraction, political corruption, failed land reform and collapse of agricultural production, environmental change, and runaway inflation. AIDS is a powerful stressor with an additional negative impact. This theme was explored for Malawi before. That country’s plight is described as a ‘perfect’ storm that brings together climatic disaster, population pressure, poor governance, impoverishment, the AIDS pandemic, the long-standing burden of malaria, and other communicable diseases.

What will it take for HIV/AIDS to tip a country into collapse?

What do we mean by ‘collapse’? Zimbabwe continues to exist, as does Malawi. South Africa and Uganda have seen economic growth and nation-building despite the epidemic. AIDS is not seen as a cause of state failure because: the impact of the epidemic is still to be felt; societies are resilient, surprisingly so, and while we have yet to see a country disintegrate, deep and increasing poverty and misery are clearly evident; and life is messy – how do we sort the impact of AIDS from the many other stressors that these people and countries face?

The question is how many people are infected, and who are they?

At certain levels of prevalence the human security impact will be limited: there are 600,000 Thais living with HIV, but in a population of 65 million that is not many, and it is hard to show that the Thai economy as a whole has been affected, though of course, the deaths of these people will affect their families, and some are devastated. A million Mozambicans or Chinese may not ‘count’ as a significant loss. If those falling ill and dying are not contributing to or making demands on their national economies, their passing may not be noticed by those who do ‘count’. The conflict between human rights and ‘real politics’ and ‘real economics’ is only now being explored, and AIDS is one reason this is happening.

Where adult HIV prevalence is below 15%, available evidence suggests societies and economies survive economically and politically. If AIDS primarily affects the poor and the marginal, then it may not be the crisis driver predicted. But, for countries like Botswana, Swaziland, Zimbabwe, and Lesotho, survival may be moot. It is only over the next ten years that we will have a clearer idea of how countries survive or fail.

The political impact

 The realization that AIDS might have political impact is comparatively recent. Political scientists were slow to engage, partly because empirical data are scarce. The data-driven thinking comes from the Democracy in Africa Research Unit (DARU) at the University of Cape Town and the South African NGO, IDASA’s governance and AIDS programme. IDASA and DARU collaborate with the University of Michigan on the Afro-barometer project measuring the social, political, and economic atmosphere in Africa through national public attitude surveys. The first surveys from 1999 to 2001 were conducted in 12 countries, and by the third round there were 18 countries involved.

Political fall-out may be felt through loss of leaders and voters, changing voting patterns, and disengagement and disillusionment with the political process. Of course, all are interlinked and interact with demographics, the economy, and poverty.

In the early years, the people at greatest risk were men with money and power (and of course their partners), people who are also more likely to engage in transactional sex. Unfortunately, male political leaders fall into the category of having cash and clout, and some regard ‘access’ to young women as a perk of the office. There is evidence of increased mortality among politicians.

In Zambia, between 1964 and 1984 there were 14 by-elections caused by deaths of parliamentarians; between 1984 and 2003 there were 59 deaths; 39 between 1993 and 2003, when AIDS mortality was increasing. By-elections are expensive, costing $200,000 in Zambia. The new representatives don’t have experience and there may be less engagement between themselves and their constituents. Political parties and structures face an impact on their functioning, as loss of institutional memory and experience is pervasive.

The focus above is on national parliaments, but AIDS is felt at all tiers, including local government from province or district to municipality or town. It will also have an effect on other non-elected leaderships including chieftaincies and traditional leaders. AIDS illness and death affects those charged with planning and conducting elections. Civil servants and electoral commission officers are not immune to infection, and the nature of their work and mobility may result in greater exposure to risk.

Impact on voter numbers and engagement manifests itself in different ways. Most obvious is increased mortality. South Africa maintains a voters’ roll. Analysis by IDASA shows prior to the 2004 election some 1.5 million deceased voters had been removed from the roll. The rate at which this is happening is increasing: 215,000 in 1999 rising to 358,000 in 2003, and mortality was higher among women voters. Over the same period the number of registered voters in the 18 to 19 age group fell by 49% for women and 54.7% for men. An analysis of the 2004 South African election suggested high HIV prevalence was correlated with a low turnout of young women voters.

Death is the measurable event, but illness is playing an increasing role. Sick people may not register or get to polling stations, and careers face similar problems. If people are increasingly ill or engaged in caring, levels of political engagement may decrease – citizens simply do not have the time, energy, or inclination to be involved. It is believed that participation in democracy is a ‘good thing’, but lower turnouts de-legitimize the process. AIDS could make a difference if it tips power balances, for instance where one ethnic or religious group has higher prevalence than another, and the voting is on ethnic or religious lines, as may occur, for example, in countries with both Muslim and non-Muslim populations such as Nigeria and some East African states.

HIV/AIDS could be important as a political or election issue, although this has not happened yet. Indeed in the Afro-barometer surveys, the primary problem identified is unemployment. In the first round of surveys, we were surprised to find HIV/AIDS featured prominently on the public agenda of only three Southern African countries: 24% of Botswana, 14% of Namibians, and 13% of South Africans cited HIV/AIDS as one of the top three problems facing their country. In contrast, just 4% of Zimbabweans, 2% of Malawians, and less than 1% of Basotho mentioned it as something government should address. Even more puzzling was that public prioritization of HIV/AIDS did not vary with the actual extent of the epidemic. However, ‘health’, including HIV, is growing in importance.

HIV/AIDS might lead to the development of broad social movements. The Treatment Action Campaign (TAC) in South Africa has been held as a model of such an organization. Many members of the TAC argue, though, that they are loyal African National Congress members and their disagreement with government is only around HIV/AIDS. In South Africa, where we would expect AIDS to be highly politicized, it has not been an election issue. In other settings AIDS has apparently been used to stigmatize candidates. For example, ahead of the March 2001 election in Uganda, Time magazine published an article quoting President Museveni saying of presidential candidate Dr Besigye: ‘Besigye is suffering from AIDS.’

At the time of writing there are numerous examples of grassroots responses to the epidemic, from nutrition to orphan care. There are home-based care groups, and lobbying and advocacy movements pressing for reduced drug prices. However, these are still to unite politically and there are few examples of health being the driver for such mobilization.

While the direct links between AIDS and politics may be hard to identify and measure, there is cause for concern about the indirect ones. Social scientists identify three key factors for sustaining and consolidating democratic rule. First, it is harder for poor countries to maintain democracy, and contracting economies and growing inequality severely threaten democratic processes. Second, there need to be strong political institutions including civil services, judiciaries, and executives. Third are the attitudes – people must want democracy. AIDS could affect all these factors.

Government and delivery

 Increased illness and death does not just affect political process. It will also influence government, particularly the civil service. Civil servants are paid less than they might be in equivalent roles in the private sector, and they expect other forms of compensation: security, sick leave, pensions, and better benefits, including death benefits. In some developing countries a civil servant can anticipate, in the event of chronic illness, six months of sick leave with full pay followed by six months on half pay. This may be further prolonged as terminating employment may require a medical board to be convened. State pensions may be paid to the wives and children of those who die in service. Under normal circumstances, these benefits should be affordable; AIDS makes the circumstances abnormal. In most work forces the mortality rate would be about 0.4%; approximately 4 in every 1,000 workers will die in a given year. Analysis of employment data suggests that AIDS increases this to between 3% and 6%, between 30 and 60 workers per 1,000.

Abnormal illness or deaths among civil servants mean government efficiency is reduced, affecting service delivery at all levels, from the schools and hospitals to the ministries. If there are no agricultural extension workers, then output in the agricultural sector will suffer as farmers lack input and advice. The illness of a customs officer may mean that goods are not cleared, an industrial process slows down, and the competitiveness of the country declines. And of course many of the best people are poached by international agencies and NGOs, paying salaries well above those of government.

Data on absenteeism and deaths in the public sector and their effects are surprisingly hard to obtain. In Malawi, absenteeism was due to personal illness, caring for sick people, and attendance at funerals. The police service saw the number of days lost due to illness increase two and half times from 1993 to 2000. The CIHD analysed personnel records for professionals in parts of the judiciary in Zambia between January 2002 and August 2005, and found that chronic disease caused annual attrition of 4.4% in the court system. Many court cases had to be adjourned because of illness, and the risk that a case would be dismissed (rather than reaching a verdict) increased by 3.5 times when illness caused adjournments.

There has been analysis of the effect of AIDS on the demand for services (increased requirements for health care, the needs of orphans, food insecurity) and the ability to provide (the change in health and education work forces, growing demands on the budget). One area that has not been researched is the effect of AIDS on revenue streams: how will AIDS affect the tax base and the ability to collect revenue?

International governance

 The AIDS epidemic has given rise to a new United Nations agency (UNAIDS), and a new international funding mechanism, the Global Fund. It has resulted in bilateral aid funding flows being increased and redirected. When in January 2003, US President Bush announced PEPFAR, the US$ 15 billion budget was the largest sum ever promised to respond to a disease.

AIDS was the first disease to be debated in the Security Council and has consistently been high in global public consciousness. There are frequent meetings, and the largest, the bi-annual International AIDS Conference, attracted a record 26,000 participants in 2006. There are numerous journals and news groups serving scientists, social scientists, activists, and pressure groups. A Google search for ‘AIDS information’ returns 189 million hits, whereas one for ‘malaria information’ gets 11.3 million.

Given the intense interest and focused activity around the disease, we must ask has AIDS affected international politics and international relations. The answer is, surprisingly, not that much. The initial fears that HIV-positive people would be discriminated against, excluded from international travel, and labeled as public health menaces did not materialize. This was thanks to the activities of health and human rights activists such as the late Dr Jonathan Mann, one of the giants of the AIDS field.

Mann worked as a physician and public health specialist on HIV in Kinshasa until 1986, then set up the Global Program on AIDS at WHO. In 1990 he established the François-Xavier Bagnoud Center for Health and Human Rights at Harvard University, and he was influential in the decision to switch the 1992 International AIDS Conference from Boston to Amsterdam because USA immigration authorities required HIV-positive people to declare their status. He was tragically killed in an air crash in 1998.

HIV is, correctly, not seen as a threat to the rich world, where it is generally restricted to clearly defined and mostly marginal populations. ART means those infected can be treated, so that AIDS is seen as a chronic, controllable disease. However, if growing numbers of infected people migrate into the developed countries as asylum seekers, economic migrants, or ‘medical refugees’ – people who can’t access drugs in their own countries – this may change. In countries where access to health care is a right, there will be public debate on who receives treatment and what the rights of asylum seekers and illegal migrants are. This, and funding, will be the focus of the international politics of AIDS for the rich.

HIV/AIDS can be contrasted with SARS and avian flu. SARS effectively closed down part of Asia and Canada. A teacher from the small rural Canadian town of Perth, Ontario, described how staffs were banned from traveling to Toronto at the height of the scare. Avian flu is seen as a major threat to global health and has produced similar panic. In early 2006 in Toronto, I saw packs being marketed to protect travelers against infectious disease (by implication avian flu) – each pack contained a mask, a pair of medical gloves, two antiseptic hand wipes, two antimicrobial wipes, and a thermometer!

Providing treatment for HIV/AIDS is big business. In mid-2005 there were an estimated 350,000 people on ART in Europe and these drugs have to be taken for life. The WHO estimated in mid-2006 that 6.8 million people in low-and middle-income countries would benefit from ART and 1.65 million people (24%) were getting treatment. The access to, and costs of, treatment are discussed in next text. The politics of AIDS treatment is linked with human rights, foreign assistance, and business. Providing drugs, carrying out research, and working with trade agreements and patent law are complex issues and part of international health governance.

International aid for HIV/AIDS programmes has grown substantially. An analysis of foreign aid presented by Washington-based researchers from the Center for International and Strategic Studies and the Kaiser Foundation at an international meeting in Paris in March 2006 showed that total commitments grew from US$ 63 million to US$ 104.4 million between 2000 and 2004 (however, this does not consider the fall in the value of the dollar and inflation). As a proportion of aid the funding for health increased more slowly from US$ 8.5 billion to US$ 13.5 billion.

Money gives rise to governance issues. There is a significant gap between commitments and actual spending. Indeed, when promises are tracked it becomes evident that the same pounds, dollars, or euros may be promised repeatedly by politicians. The PEPFAR commitment was unusual because so much was new (US$ 9 billion). Money comes with strings attached. These include what Americans call ‘pork-barrel’ issues, making sure that ‘your’ consultants and suppliers get the contracts – this is straightforward ‘business’. But funds also flow in ‘silos’ for prevention or treatment, for AIDS or TB. There are issues of accounting and reporting, and each donor has their own requirements. Then there is the question of sustainability. Aid flows are partly dictated by fashion – this decade AIDS, next environmental issues?

Recently, ideology has come to the fore; programmes get preference if they promote certain issues, such as abstinence, or can’t attract funding if they promote others, such as needle exchange. Originally the US Congress required that 55% of PEPFAR money should be for treatment, 15% for palliative care, 20% for HIV/AIDS prevention, and 10% for orphans and vulnerable children. Of prevention money one-third was to be spent on ‘abstinence until marriage’ programmes. Half the money for orphans had to be channeled through non-profit, non-governmental organizations, including faith-based organizations.

Global health governance is in a parlous state, with weak leadership and little coordination. Public health is simply not on the agenda. Responses are geared to imminent threats and not ones in the future. The WHO should be the place to look for leadership, but at the moment it is neither respected nor well run. Because it answers to the member states, it is difficult to envisage how it might change. UNAIDS offers some hope but has insufficient resources and constantly has to fight the danger of becoming bureaucratic.

At the moment, HIV/AIDS is the global health issue receiving the most attention and funding. At the World Economic Forum in Davos in January 2006, Nigerian President Olusegun Obasanjo, UK Chancellor Gordon Brown, and philanthropist Bill Gates called for world leaders to rally behind a major new action plan to treat 50 million people and prevent 14 million tuberculosis deaths worldwide over the next ten years. The initial cost was estimated at US$ 56 billion. In the same month, a meeting in Beijing called for US$ 1.2 billion to combat avian flu – and US$ 1.9 billion was pledged. Each disease has its advocates, and while AIDS dominates currently, this will change.

The politics of providing good health are not simple. HIV and AIDS are prime examples of where our responses have fallen miserably short of what is needed. AIDS provides a chance to examine global health governance and make changes. It is not, in the bigger picture, a threat to global security or economic development, but will become a long-term international problem that we will come to live with and accept at a global level.

At the local level, AIDS puts the continued existence of the worst affected countries in doubt. African societies where the population goes into decline, life expectancy plummets, most children are either orphaned or live in families that have taken in orphans, and where the gender balance by age changes dramatically, cannot function in a way that we consider to be ‘normal’. In former Soviet countries, the high levels of infection among ‘scarce’ young people will have severe consequences. For families and communities, AIDS has devastating impacts.